The nurse is caring for a client with a spinal cord injury at the T6 level who suddenly develops a blood pressure of 200/100 mm Hg and a headache. Which condition does the nurse suspect?

Correct Answer: B

Rationale: BP 200/100 and headache in T6 SCI suggest autonomic dysreflexia (B) from a stimulus below the injury. Neurogenic shock (A) has hypotension. Hypovolemic (C) or septic (D) don't match. B is correct. Rationale: Dysreflexia's sympathetic surge above T6 triggers hypertension, per SCI emergency care, requiring immediate stimulus removal.

Correct Answer: D

Rationale: Eyedrops are administered into the lower conjunctival sac formed by pulling the lower eyelid down ensuring medication spreads across the eye evenly when the patient blinks. This maximizes absorption and minimizes runoff, critical for efficacy (e.g., glaucoma drops). The inner canthus (near the nose) risks drainage into the tear duct, reducing dose and potentially causing systemic effects. 'Other canthus' likely means outer canthus (lateral), less effective for retention, as it's not a sac. The upper conjunctival sac is harder to access, requiring awkward lid lifting, and less practical. The lower sac's anatomical suitability holding drops naturally makes it the standard site, ensuring therapeutic delivery and patient comfort, per ophthalmic administration protocols.

Correct Answer: C

Rationale: Pain radiating to Mr. Gary's upper right quadrant is referred pain (C), where sensation is felt away from its source, per pain types (e.g., gallbladder to shoulder). Acute (A) and chronic (B) describe duration, not location. Phantom (D) is post-amputation. Referred pain aligns with anatomical nerve pathways, common in visceral issues, making C correct for this pattern.

Correct Answer: B

Rationale: Reporting bruising indicates understanding of warfarin's anticoagulant effect, as excessive bleeding is a key risk in atrial fibrillation management, requiring physician oversight reflecting proper teaching. Spinach (high vitamin K) counters warfarin, blood tests (INR) are routine, and dosing is daily, not weekly. Nurses reinforce this vigilance, ensuring clients monitor for bleeding to balance clot prevention with safety.

Correct Answer: B

Rationale: Helping the family accept the condition (B) best describes the nurse's role, per palliative nursing supporting emotional adjustment. Medical advice (A) is physician-led, mediation (C) secondary, leaving alone (D) neglects duty. B fosters coping, making it correct.

Correct Answer: C

Rationale: Radium implants emit radiation, requiring nurses to wear lead aprons to shield against exposure during care, minimizing health risks. Visitor restriction limits exposure but isn't the primary nursing action. Urine doesn't need lead storage unless radioactive contamination occurs, and IM injection sites depend on practicality, not radiation. Safety protocols prioritize protective gear, ensuring staff and patient well-being during brachytherapy.

Correct Answer: B

Rationale: Parallax error occurs when eye level misaligns with the mercury meniscus e.g., higher eyes read lower (false low), lower eyes read higher. Eye-level accuracy is key. Nurses position e.g., at meniscus height for true BP, per measurement precision principles.

Correct Answer: B

Rationale: Fluid status in burn patients is critical due to massive losses from damaged skin. Electrolyte levels (choice A) indicate imbalances but not volume status directly. Hematocrit (choice B) measures blood concentration; in burns, it rises with hemoconcentration from plasma loss, making it a practical indicator of fluid shifts. Creatinine level (choice C) assesses kidney function, indirectly reflecting hydration over time, not acutely. Hemoglobin level (choice D) tracks oxygen-carrying capacity but is less sensitive to immediate fluid changes. B is correct, as hematocrit provides a rapid, reliable gauge of fluid resuscitation needs. Nurses use this, alongside urine output, to titrate IV fluids, preventing shock or overload in burn management.

Correct Answer: B

Rationale: Yellow CSF (B) indicates subarachnoid hemorrhage due to xanthochromia from blood breakdown. Hazy (A) suggests infection. Brown (C) or colorless (D) don't fit. B is correct. Rationale: Xanthochromia confirms bleeding, a key diagnostic sign, per neurology standards, distinguishing it from other CSF changes.